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advice and anecdotes from a retired psychiatrist (shrink)

mental health

Many years ago I treated a patient who was suffering from a near fatal case of loneliness.

No, I am not exaggerating for this person would later confess that she had come to me in a last-ditch attempt to resolve her problems while promising herself that if I couldn’t help she would hang herself. She was a 20-something attractive and very modestly dressed woman who did indeed look very despondent with the psychomotor retardation and furrowed brow characteristics of clinical depression. When I asked her why she was there to see me, she hung her head, stared at the floor, and tearfully responded that she had been shunned.

She went on to tell of how her infraction of the church’s rules (one that most of us would consider a minor infraction) had resulted in her being officially designated as one with whom the entire church should have no contact whatsoever. You may be thinking: “Big deal go find another church.” But her story was more complicated. She had grown up attending this church. It was the center of not only her spiritual, but also her social and family life. Since the church doctrine insisted that only members of their church were true Christians, the members were warned about the dangers of consorting with people outside the church, apparently convinced that sin was contagious. Thus, when alienated from the congregation, which to make matters worse, included her entire family, she found herself totally alone.

Such stories are not new as evidenced by Nathaniel Hawthorne’s tear-jerker, THE SCARLET LETTER, but give witness to the importance of relationships and the pain of loneliness. Many religions have used banishment of varying degrees of severity to punish wayward members. The Catholic Church’s policy of excommunication appears to be less stringent and is viewed by the church as a means to save souls whereby one can return to the fold and regain salvation by repenting. Such tools are powerful and their use can have long lasting effects. For example, I recently discovered that my Great, Great, Great Grandfather was shunned and ejected from the Quaker church. It occurred to me that if he had toed the line, I might be a Quaker.

AND YOU THOUGHT SMOKING WAS BAD

Solitary confinement has long been used as a means to enhance the discomfort of imprisonment, and is agreed by many to be a form of torture. In a previous blog, WHAT’S LOVE GOT TO DO WITH IT? I contended that our need for relationships is encoded in our DNA, having evolved long ago as a major contributor to the survival of our species. If one were to accept that premise, it would be logical to assume that loneliness could be a major problem for us. Indeed, according to Vivek Murthy, M.D., the former Surgeon General of the U.S., loneliness has become “a growing public health crisis.” He has said that loneliness is a more effective agent in reducing longevity than obesity, and that its toxic effects are worse than smoking 15 cigarettes per day. Recent research into the prevalence and effects of loneliness tends to confirm Murthy’s assessment. Last year Cigna released a report on a study of 20,000 people age 18 and over as measured by the UCLA loneliness scale.

Nearly half reported loneliness as a problem, but even more concerning was that 27% felt no one understood them, and 43% admitted they felt their relationships were not meaningful. One in five felt they rarely or never felt close to others or that there was anyone they could talk to. It was also noted that Generation Z (those born after 1996) were the loneliest of all the generations measured.

There have been a number of studies which confirm the effects of loneliness on physical and mental health. It is not surprising that it could result in affective disorders such as depression, and may help explain the increase incidence of suicide as mentioned in my previous blog, but there is also evidence that loneliness can cause or aggravate innumerable maladies including: hypertension, coronary artery disease, dementia, inflammatory diseases such as arthritis, impairment of immune systems, and even some malignancies to name a few.A study in the Archives of Internal Medicine sponsored by the National Institute of Health followed 1604 people over the age of 60 (average age 70) for 6 years and measured their physical decline and mortality rate. Their stark conclusion was: “Among participants who were older than 60 years, loneliness was a predictor of functional decline and death.” Need I say more about our need to engage with our fellow man?

WE ARE NOT THE ONLY LONELY

It turns out that we are not the only nation where loneliness has become a problem, both from a public health and productivity perspective. Great Britain’s parliament has recently appointed a commissioner to investigate remedies for what has been called a silent epidemic after a study showed that 20% of Brits reported they were lonely most or all of the time. It appears there are similar studies in progress in other European countries. It would be helpful to know if loneliness is a worldwide problem or peculiar to our culture.

NOTHING ELSE TO DO

If one accepts the premise that loneliness is a significant problem, the question arises as to how did we get this way and what can we do about it. Prior to the industrial revolution, multi-generational families provided a sense of belonging. Relatives galore, including parents, siblings, cousins, grandparents, aunts, and uncles usually lived in close proximity. With the switch from an agrarian to an industrial society, there had been a migration to cities where houses were built close together, which resulted in the development of neighborhoods usually composed of people with common interests. There was the inevitable clustering of children who interacted with only minimal adult supervision, and stay-at-home moms who could relate to each other in a very personal way. Neighbors were evaluated based on certain standards including friendliness and mutual respect. The lack of air conditioning and television made front porches very popular especially on hot evenings, and provided an opportunity for informal socializing. The only taboo subjects were sex, religion, and politics.

BETTER THINGS TO DO?

Soon after World War II ended, front porches began to disappear from neighborhoods, and there was a wild rush to the suburbs where large green lawns were treasured and families had fewer opportunities to be “neighborly.” On hot summer nights, it became more comfortable to be inside the house (with air conditioning) than outside. There were also new-found entertainment devices available – first radio, then TV, movies in the VCR and then DVD Player, video games, and then the internet which gave us social media and streaming. One could go for months or longer without ever having face-to- face contact with one’s neighbors. There was no longer danger of an errant foul tip sending a baseball through someone’s window. Privacy became important, and it was no longer considered a snub to build a fence between houses. There were no kids playing hopscotch on the sidewalks, as a matter of fact, there often were no sidewalks in these new neighborhoods.

Competing Schedules and Activities

As more mothers joined the workforce and children were exposed to more structured extra-curricular activities, long-held family traditions changed. There was concern about the “latch key children” so named because they would come home to an empty house. The evening meal, often the only time in which the entire family came together, was often disrupted due to conflicting schedules. This led to the so-called crock pot families where the family meal was available to all who passed by…making it easy to just grab a bite and be on your way without any hassle (or conversation).

WHY SO MUCH LONELINESS?

It is ironic that in this digital age when we have vastly improved modes of communication, that we would identify loneliness as a problem. Facebook’s founder, Mark Zuckerberg, insists that he saw his invention as a tool by which relationships could be fostered throughout the world and help dispel feelings of loneliness and dissention, but it appears that it has done more to promote divisiveness and distrust.

With the invention of the telephone we gave up non-verbal cues in our conversations, and the trade-off for its convenience seemed like a good deal. Now kids have largely given up talking on their cell phones in favor of texting. Voices from the internet, news media and politicians all conspire to promote divisiveness and paranoia to the point that it is almost impossible to have a rational conversation about many of the issues of the day.

It has been said that Americans are losing faith in our institutions, and our political leanings are often shaped by who we hate rather than who we like. Political discourse has hit a new low. Muck raking is no longer good enough, and has been replaced by personal insults a la grade school rants. Respect for contrary opinions has now gone out of fashion. Divide and conquer is the new strategy, and a tactic that seems to have even been adopted by the news media (Matt Taibbi has written an entire book about it, called “Hate Inc.”). We lack heroes. We frequently hear the term “disenfranchised” these days, a synonym for “left out” and to be an outsider is lonely for any herd critter.

ALL IS NOT LOST (stay with me…a little break from “downer” time)

There is some evidence that there may be some efforts underway to deal with the loneliness issue. I was pleased to see a recent article in Psychiatric News suggesting that psychiatrists are focusing more on loneliness as an underlying psychiatric problem (don’t know why it took so long to figure that out). A former president of the American Psychiatric Association has suggested that assessment for loneliness be part of any evaluation or perhaps become a diagnostic category in the DSM 5 (the shrink bible). There is also a growing awareness of a worldwide suicide epidemic which most would agree loneliness all too often plays a part. Lonely lifestyles also frequently seem to be common with mass murderers.

LONELINESS VS. BEING ALONE

Proximity to other people is not necessarily a solution for loneliness, for it is not unusual to feel lonely in the midst of a crowd. Obviously, some type of emotional engagement is necessary to dispel lonely feelings. Ordinary discourse involves much more than words. Unfortunately, in our digital world many of the nuances of communication are lost. Not only are the tone, rhythm, volume, and timbre involved, but there are multiple non-verbal cues which can modify or even completely change a communication. As a matter of fact, some very significant interactions may occur without any words spoken. In that vein a text hardly measures up to a face to face encounter as a means to communicate feelings.

Emotional tone is less relevant, for even an argument can dispel lonely feelings.
Although, until recently, there have been few attempts to measure the extent of loneliness, there is definitely a consensus among sociologists and mental health professionals that there has been a definite increase. Employers have taken note of recent research which has shown that employees are more productive when they are encouraged to interact with each other. As a consequence, in many cases the traditional office cubical arrangement has been scrapped in favor of a more open environment, teamwork is encouraged, and brief chats at the water fountain are less likely to result in a dirty look from the boss. Since most workers spend nearly half of their waking hours in the workplace such changes could be very beneficial for large segments of society.

GO TEAM

The needs for engagement with other humans has long been addressed by the formation of millions of organizations that bring groups of people together with myriad goals, but which also provide an opportunity to relate to others. The sense of belonging to a group is a powerful antidote to loneliness. Young people who feel neglected or alienated are more likely to join street gangs (easier to radicalize for terrorism and/or recruit for “religious” cults*). Athletic events and concerts attract millions, most of whom “show their colors” and cheer as one. One of my all-time favorite TV shows was Cheers which identified the locus of the show as the place “where everybody knows your name.” Organizations of all kinds including sports teams, military, and political groups or for that matter any group of people with a common goal make use of the need to belong which at the end of the day is an antidote to loneliness.

THEY NEED EACH OTHER

AARP sponsors a very interesting and apparently successful program called “Experience Corps” in which volunteer over 50 are enrolled in a program where they are trained to help children develop literacy skills. They spend 6 to 15 hours per week working with K-3 students with spectacular results including as much as 60% improvement in reading skills, fewer behavior problems, improved attendance, and increased graduation rates The AARP foundation at last report had 2,000 volunteers throughout the country serving over 30,000 students. However; it appears the volunteers may be benefiting more than the kids from the program. A University of Michigan study reported a statistical decrease in depressive symptoms and functional limitations among the volunteers after two years involvement in the Experience Corps. There may also be a secondary benefit in that some kids may learn to venerate rather than denigrate us old folks. (Score 1 for the Old Farts!)

BE CAREFUL WHAT YOU WISH FOR

None of this should be interpreted as an attempt to diminish the value of solitude. Certainly, this need to relate can be overdone, and in some cases become pathological. In many cases of marital therapy, for example, too much togetherness can be identified as the problem. In testimony before Congress, Prof. Julianne Holt-Lunstad defined loneliness as ” the perceived discrepancy between one’s desired level of social connection and their actual level of social connection.” She explained that some people who are socially isolated don’t necessarily feel lonely, and some people who are lonely are surrounded by people who make them feel more alienated.

One’s work may require so much contact with others that it can become oppressive, and some personalities may cause anal pain of the worst kind! Nevertheless; before you make plans to spend the rest of your life on a deserted island or join an order of non-verbal monks, be careful what you wish for. Time-alone can be refreshing, relaxing and creative, but as with most things in life, it can be overdone. Alone can be good, but lonely can be very bad. In this time in which we are all mutually dependent, it has become even more necessary to have relationships than we did in those days when we needed help to bring down a woolly mammoth. It is difficult nowadays to survive in this world as a loner. We face enormous problems including an increased global population, competition for resources, and degradation of our environment. It is once again time for us to hang together or hang separately.

WHAT MAKES THEM TICK?

The ability of the human race to relate to each other has allowed us to survive and to thrive. We need to exercise that talent now more than ever. As I finished writing this, once again two hate-filled young people described as loners committed horrible atrocities within hours of each other. It goes without saying that we need to take logical steps to limit access to those instruments designed to kill people, but the prevalence of these kinds of behaviors also require us to learn more about the milieu in which they occur. For example: are there genetic influences involved, does our society in some way generate such hatred, are certain personalities more easily recruited to violent organizations, is shyness a precursor, and finally does the hatred cause the loneliness or vice versa? We need to understand more about how these people end up the way they are if we are to have any success at solving the problem.

If you have read any of my recent blogs, you may have noticed the following quote from Lao Tsu, an ancient Chinese philosopher: “to be loved deeply gives you strength, to love deeply gives you courage.”

The wisdom of those words explain much about behaviors I observed and attempted to treat as a psychiatrist. Feeling unloved was indeed a common complaint and the cause of a great deal of pain and misery. Without the experience of feeling loved one is weakened, and thus may lack courage to face even the ordinary demands of life. This may progress to a conviction that one is not only unloved but unlovable, resulting in self-loathing, depression, thoughts of harming oneself, and according to Anthony Storr, may generate violent aggression which he says is: “a complex mask for a repressed longing for love.”

WHY DO THEY DO IT?

There seems little doubt that we are now in the midst of an era of increased incidence of depression and unsanctioned violent aggression. Mass murders by otherwise ordinary people of all ages are now occurring at a level never before seen in the U.S. Most perpetrators have a history of relative anonymity. Neighbors usually describe them as quiet and unassuming, a person to whom they would speak to in passing but never engage in conversation. Acquaintances when found describe their relationship as superficial, and express profound surprise that the person was capable of violence. There is little evidence of any closeness let alone intimacy in their lives. Could such horrible deeds be as Storr said: a result of anger over the lack of love in their life?

THE THIRD MOST COMMON CAUSE OF DEATH

There has been an alarming increase in the number of kids diagnosed with clinical depression which is not limited to those who are disadvantaged or abused. A recent Center for Disease Control and Prevention survey of young people between the ages of 10 and 24 years resulted in shocking statistics. They report 4600 lives lost each year by suicide (most experts feel the actual number is higher due to a tendency for many to go unreported), and that rate has nearly tripled since 1940. Emergency rooms throughout the country report 157,000 young people treated for self-inflicted injuries each year. In their Nationwide survey of high school students, the CDC reported 13% admitted to seriously considering suicide, and 8% actually made an attempt to take their own life. The report goes on to list a number of risk factors however; at a time in their lives when they are dependent on others to establish an identity and self-worth, it seems to me that relationships deserve to be at the top of the list. Indeed, many teen-age suicides do implicate such problems as precipitating factors.

MORE OF THE SAME, ONLY WORSE

Rollo May in his 1960’s book LOVE AND WILL, says “Our culture pushes people toward becoming more detached and mechanical,” but that observation doesn’t come close to what we see now that the digital age has enveloped us. The addiction of our children to cell phones and other electronic gadgets contributes to their alienation. Consolidation of schools and overcrowded classrooms have made it easier for kids to fall through the cracks. Social media has become a convenient vehicle through which kids can be disparaged or bullied. They are often attacked where they are most vulnerable i.e. their lovability consequently; the common theme “no one likes you” can be devastating to developing minds. Now we hear there has been a dramatic increase in suicides in recent years among not only teenagers but pre-teens. Although there is no proof of a link to feeling unloved, logic suggests there often is.

DON’T CARE? SURE YOU DO

There is ample evidence that we are herd animals, consequently; it is not surprising that I spent many hundreds of hours listening to patients with relationship problems, for when people are so very important in our lives, dysfunction can present problems. Although we often attempt to comfort ourselves by professing to not care what others think, in truth we usually do care more than we would admit. During all those years I spent in the shrink business I must have seen hundreds of people who were contemplating suicide or had actually made serious attempts. Although there are obviously many factors that may lead one to seriously consider killing oneself, I recall often hearing: “Nobody cares.”

DO WE KNOW WHAT IT IS?

It would indeed be presumptuous of me to attempt to explain what love is all about. It has certainly been a popular topic for poets, philosophers, musicians, theologians, and artists, through the ages. The stories of wonder, ecstasy, and tragedy associated with love resonate in pop culture to this day. There have been myths, and legends and attempts to define love by categorizing it (erotic, agape, filial, spiritual, etc.), but the force responsible for this peculiar phenomenon remains a mystery to me. My favorite definition of the term is from psychoanalyst Harry Stack Sullivan, as follows:

The validity of such explanations is confirmed by the intense love relationships experienced by warriors throughout the ages. The myriads of reports of heroic efforts put forth by battle hardened veterans to protect their comrades, even risking or forfeiting their lives in the process gives credence to Sullivan’s ideas. Indeed, when questioned as to why those who would in other situations have been considered unlikely heroes are questioned about their behavior, they will acknowledge that it had nothing to do with military or political beliefs, or patriotic fervor, but rather their devotion to their buddies (“No greater love hath man……”). That phenomenon has not been lost on those charged with training the military, consequently; camaraderie is encouraged and interpersonal dependency guarantees bonding. One cannot wonder as to the part that the loss of relationships, solidified by the heat of battle, factor in the alarming rate of depression and suicide among our veterans. Many report they worry about their comrades who are still fighting which may also account fir the significant number who volunteer for additional tours of duty with their old outfits in spite of the known horrors they will likely confront.

WORTH THE TROUBLE?

Obviously, love has been a major contributor to the success of the human race. Humans isolated from their kind rarely survive. Sullivan posits that love is caring for others as for oneself and the old Chinese dude says as a result of love for each other, man gained the strength and courage to take on woolly mammoths and those guys in the next village who were trying to muscle in on their territory. It is the latter part of that statement that has caused a lot of problems. We seem to know a great deal as to the effects of love, but little about from whence it comes. The neuro-physiologists and brain mappers continue to look for specific love loci, and geneticists will likely say that it is in our DNA, but I doubt that CRISPR will ever be able to install a love gene. It would be great if such could be done, for we currently have little treatment for those who seem incapable of love, i.e. psychopaths.

I KNOW IT WHEN I FEEL IT

It may be that love is like the dark matter of our universe in that we know it exists and feel its effects even though we are unable to see, hear, smell or touch it. Could it be that love is simply a product of evolution? If so, how could we have survived long enough for natural selection to kick in? The creationists insist that God snapped his fingers and we instantly appeared on the scene fully equipped. Atheists on the other hand think the whole thing was an accident. Others see love as spiritually endowed. There are 4300 religions in the world with Christianity leading the pack and Muslims close behind.

WHAT ABOUT RELIGION?

Since I have been reared as a WASP, I have very little understanding of the other religions of the world or in particular where they stand on the love thing, but am pleased that love is at the core of Christianity. When it comes to Biblical scholarship, I am a dunce, but I do find inspiration in those first few pages of Corinthians which are all about love. The first 2 of the 10 commandments are also about love, and love is said to be the greatest of all, never fails, and is even better than faith or hope. There is also that thing about loving your enemies and turning the other cheek, but most of all were the teachings of Christ who was all about love. Of course, many see an inconsistency in a loving God who lets crappy things happen in spite of being all-powerful. Since Christians are people it is not surprising to find they have found ways to subvert the love philosophy, and resort to violence with all sorts of rationalizations.

Loving others as much as oneself is a great idea, but very difficult to implement on a grand scale. Excessive cheek turning is guaranteed to result in a lot of broken jaws. Nevertheless, there have been many attempts to use love as a mechanism to provide peace and tranquility, which has been met with success in some instances. In a rare instance of wisdom, our government eschewed the policy of gathering the spoils of war after WWII. Instead they initiated a policy aiding even our enemies to rebuild their virtually destroyed countries which lead to their becoming our closest allies. Of course, I was also around during the “love ins” of the sixties. Although they seemed to have emphasized the erotic rather than agape version of love, they did call attention to long neglected human rights issues and war mongering. There was also Nelson Mandela and Martin Luther King who both emphasized reconciliation and learning to love each other.

We certainly could use more love in this world, but the chances of EVERYONE following the Golden Rule seem to be unrealistic. Nevertheless, when I look back on our history it seems there has been some progress in the love department with more emphasis on inclusivity and acceptance. Although it may seem that love is in short supply, it is alive in well and we can only hope the day will come when The Golden Rule is ever present. Even as millions of our fellow humans face horrors each day, there are millions of people who devote their lives to helping others individually and through organizations, which gives credence to the dictum that love never fails.

Corinthians 13:4-8 gives tells us everything we need to know: “Love is patient, love is kind. It does not envy, it does not boast, it is not proud.It does not dishonor others, it is not self-seeking, it is not easily angered, it keeps no record of wrongs.Love does not delight in evil but rejoices with the truth. It always protects, always trusts, always hopes, always perseveres. Love never fails…”

It appears that Marijuana use has now become a socially acceptable practice. Not only are states falling in line to legalize recreational use (I don’t like that term for it seems to equate smoking weed to working out at the gym), but I was surprised the other day when I happened on to an interview with Liz Post who is the great granddaughter-in-law of Emily Post, the etiquette guru. Liz has taken up the etiquette banner and continued as director of Emily’s foundation for the last 30 years. She has written her own books of etiquette, this latest of which caught my attention. It is titled Higher Etiquette, and is all about proper behavior in marijuana involved social situations.

A few days later, I was confronted with a full front-page spread in our local newspaper about our county’s latest industry, a facility for growing marijuana on a large scale. It was hailed as a major success for the area and projected that it would eventually employ more that 100 people.

The story featured a half-page picture of the interior of a huge greenhouse inhabited by large plants. Apparently, since the owners realized potheads would see the photo as their idea of heaven on earth, they assured us that the facility would be heavily guarded. Medical marijuana (whatever that is) was legalized in our state in September 2016.

The new law only authorizes the use of cannabis orally or topically in the form of pills, elixers, tinctures, and lotions etc. Dispensaries were licensed by the state and product can be obtained with a note from a licensed physician confirming that the person is suffering from one of a list of 21 maladies; although the state medical board is authorized to add diagnoses to the list as they see fit. The law prohibits home growing of weed and smoking it, but allows inhalation through a vaporizer. (I would anticipate there will soon be a brisk business in vaporizers). Not only does this and similar laws across the country violate federal law governing the use of marijuana, it appears to me to bypass Federal Drug Administration procedures which require extensive testing for both efficacy and safety before any drug can go on the market.

Efficacy of Cannaboids

There is a great deal of anecdotal information concerning the efficacy of cannabinoids for a variety of medical problems. In the early 1800s an Irish physician found cannabis extracts helpful in relieving stomach pain and nausea in people suffering from cholera, and recently the FDA approved 2 drugs containing THC, Marinol and Syndros, for treatment of nausea and anorexia in patients undergoing chemotherapy for cancer. It is also said to be useful in the treatment of refractory epilepsy, chronic pain problems, glaucoma, and various neuromuscular diseases such as multiple sclerosis to name a few. Prior to the dawn of modern pharmaceuticals, cannabis extracts were widely sold as a treatment for stomach ailments. Now, nearly 200 years later we don’t know much more about them than we did then.

Other Naturally Occurring Plants in Medicine

This is not the first time that a naturally occurring plant would be found to be useful in treating medical conditions. For example, back in the dark ages when I was a general practitioner, digitalis, which was extracted from the foxglove plant was the treatment of choice for a variety of cardiac problems. More recently, taxol, a substance extracted from the bark of the Pacific Yew tree has proven effective in the treatment of ovarian cancer.

The Problem with Pot

The fact that THC is a mood-altering drug complicates the issue of doing the proper research to discern its effectiveness, side effects, and dangers both in the short term and with prolonged use.

There is also the possibility of an enhanced placebo effect. Does drug-induced euphoria tend to mask symptoms, and if so is that bad thing?

The more significant reason for the lack of knowledge as to the effects of marijuania on the human body is due to Federal Drug Administration’s reluctance to allow scientists to possess it in order to evaluate it properly.

In 1970 Nixon signed into law The Controlled Substances Act which listed marijuana as a Schedule 1 drug along with heroin, LSD, and other dangerous and /or highly addictive drugs. This was during the time of the War on Drugs, and the FDA was so uptight that they refused to allow possession of any of these drugs for research purposes. Of course, as usual they zigged when they should have zagged for this was a time when new tools were becoming available to researchers with which to evaluate the effect of drugs on the brain, and an opportunity to learn more about the drug was lost. With such information, they could have been in a position to inform us as to the possible consequences of their use, and perhaps more specifically define how or where they might be useful or harmful.

Follow the Money

With one foot firmly planted in the door with the medical thing it is not surprising that the Marijuana Rights and Regulations Amendment will be on this fall’s ballot. It would legalize the use, possession, and sale of marijuana for persons over the age of 21, and would allow the Ohio General Assembly to enact a tax on its retail sales. As nearly as I could tell there are no proposed restrictions and if passed, potheads can rejoice at their new found freedom. Likewise, entrepreneurs would like to see some of that drug cartel money stay right here in the US of A, and why shouldn’t stoners throw a few bucks into state coffers for the privilege of getting high? Those who grow their own (in limited amount) will pay $50 for a license which is not a bad deal when one considers a cigarette smoker pays $1.97 in taxes for a pack of carcinogens.

If one follows the money, it would seem that the proposed bill would pass, and become law. According to one PR organization (ABCD Inc.) the potential profits are nothing to sneeze at. In their 2018 Cannabis Price Index, they project that in New York city alone 77.44 metric tons of pot was consumed in 2018 with a revenue of well over $8oo million, and if taxed at the same revenue as cigarettes $354 million for the city. I have no idea how they came up with those figures, but if true it is little wonder there appears to be an active campaign espousing the virtues of cannabis involving not only established stoners, but big business and politicians as well.

History of Pot

According to the DEA Museum, the oldest known written record on cannabis use is from the Chinese Emperor Shen Nung in 2727 B.C. There is some evidence that its psychoactive qualities were known then. However, the plant was used primarily for its fibers, which were used to make rope, cloth, and a variety of other products, and is thought to have been low in the concentration of psychoactive chemicals. Although hemp and marijuana are of the same species, i.e. cannabis, it is thought that one variety was developed over time with the goal of increasing the levels of tetrahydrocannabinol (THC), the chemical responsible for its mind-altering effects.

A Higher High

The process of increasing the potency of weed has continued and has accelerated during the last 20 years – not surprising since users are always looking for the “good stuff.” One study found the average potency in Europe and the U.S. to have nearly doubled between 2008 to 2017. The THC levels had gone from 8.9% to 17.1% with one variety reaching 67%.

This same study compared rates of psychosis between areas with different levels of cannabis potency and found that indeed those cities with the more potent stuff reported more psychotic episodes. As a matter of fact, those who had used higher potency stuff were twice as likely to eventually have a psychotic episode compared to those who had never used. Even more worrisome was the stat that daily users of high potency weed were four times more likely to experience psychosis. This raises the question as to whether THC may have long term side effects. This is not at all surprising; after all THC has long been categorized as an hallucinogen even though until now a weak one.

Pot and the Teen Brain

With the frightening (to some of us), statistics as to the prevalence of pot smoking among adolescent and even younger children has come realistic concerns as to the effect of pot smoking on their brains. This has become increasingly worrisome with recent discoveries of the so-called “plasticity” of the developing brain i.e. the effect that various stimuli may have on its structure and function. Such changes may not become readily apparent until years later and to that end the National Institute of Health has instituted The Adolescent Brain Cognitive Development Study that will follow 10,000 children through adolescence hoping to find what sort of factors, including drugs, affect their brains. Unfortunately, it will take many years for the study to be completed.

Not So Fast…

Although such information is incomplete, I feel it is premature to judge cannabis to be an innocuous substance, as many would have us believe. I recall similar reassurances regarding cigarettes, e.g., that they were not addictive, harmless, and simply a relaxation aid. It was true those people on billboards, in the magazine ads, and the movies looked really cool with one between their fingers. I was one of those gullible slobs who tried looking cool for 50 years, and was rewarded with a couple of cancers. I was also left wondering how much damage I had done with all that second hand smoke. Of course, I knew that I was not addicted for I could quit anytime I wanted, it was just that I didn’t want to (the same words I have frequently heard from my pot smoking patients).

We’ve Been Down This Road Before

At the beginning of the 20th century, cocaine was toted as a wonder drug with the potential to cure a potpourri of illnesses including drug addiction. Its health benefits were even extoled by adding small amounts to a soft drink which in honor of the presence of cocaine was named Coca Cola. Two of the best-known pioneers in their respective fields of medicine became addicted as a result of their experiments with the drugs. William Halsted who is credited with devising many of the surgical techniques still in use today became incapable of functioning due to his addiction as did Sigmund Freud who likewise became addicted by testing the use of cocaine for psychiatric illnesses. In the 1960s along comes Timothy Leary a Harvard psychologist who promoted more potent hallucinogens as treatment for depression, to increase awareness of otherwise untapped spiritual states of being and other kooky stuff. He was eventuallyHe was eventually disgraced when he was found to be using prisoners as subjects for his experiments.

Why?

Whenever there are discussions with anti-dopers about mood altering drugs, the question frequently arises as to “why they do it.” Freud attempted to answer that question with his “pleasure principle” theory, an idea which was a couple of thousand years old having previously been described by the Greek philosopher Epicurus. This was the idea that the pursuit of pleasure and avoidance of pain are the essence of life, and therefore all behaviors can be explained by this instinct, furthermore conforming to societal norms is simply to delay gratification of those instincts.

Addiction

The term addiction is not easily defined as it seems to be used in different contexts, but it is clear that the more pleasant the effects of a substance, the more likely it is that one moves on to an insatiable craving. With prolonged use physiologic changes occur as our body adjusts to the presence of the new substance and bad things happen when it is suddenly withdrawn. The extent of its effect on our body/brain is called its potency. A 2- pack-a-day cigarette smoker is apt to have some headaches and grumpy days for a week or so, but a very heavy use of alcohol over a long period of time can result in delirium tremors, a condition which carries a significant mortality rate when untreated. It appears that in some heroin users, the passage from craving to addiction is almost instantaneous.

Of course, the foregoing description of addiction is woefully simplistic for it is a very complex subject with much disagreement among the experts. My point is that without some regulation governing potency of cannabis we may be in for some unpleasant surprises. Having over the course of my career seen large numbers of marijuana smokers, I am convinced that it is by no means innocuous. I also question the conclusion of pot supporters that it is in no way addictive. I believe that it is especially dangerous in children and that many who are exposed at a young age may be permanently damaged.

So, What’s the Answer

Many of you may be thinking: “OK smarty pants, if it is such a big problem, what can be done about it?” The answer is not much. It is clear that the current situation has not worked except to provide opportunities for criminals to make a buck and for addicts to sell in order to finance their habits. Apparently, we did not learn our lessons from the results of prohibition. As with alcohol, cannabis is easy to produce in most any climate and even more difficult to control than opiates, which must be imported. There are some steps I think would be helpful in minimizing the problem:

For the states to continue to have their own laws about pot causes confusion. The federal government should legalize the stuff.

The FDA should set standards and monitor compliance.

It took 100 years for the realization that tobacco companies were spiking cigs with extra nicotine, we should test cannabis for potency.

Anyone who gives or sells the stuff to kids should spend significant time in the slammer (I have seen instances where pot smoking is a family affair).

Many organizations saved lives with an all-out effort to make smoking uncool, let’s give marijuana the same treatment.

With legalization will come more use, encourage NIMH to make research into the drug a priority

Please, please, no advertising. Think it couldn’t happen? That’s what the temperance union thought following the repeal of prohibition.

After pushing pills and other remedies for well over a half century I have concluded that there is usually a downside to whatever chemicals we put in our bodies regardless of their positive benefit. In spite of rigorous evaluations, clinical trials and such we often see unexpected side effects…sometimes years later. The current practice of prescribing cannabis based on anecdotal information without benefit of rigorous clinical testing is in my opinion irresponsible. Nevertheless there is little doubt we have a serious drug problem, and the consensus is that cannabis is safer than most other street drugs. Prohibition offered further proof that “the pleasure principle” thing would not be denied no matter the consequences. Legalizing alcohol did not solve the problem, but it was not as bad as the alternative, and following that model seems to me to be the more sensible approach in dealing with cannabis.

PERSONALITY DISORDERS

The other night while dining with friends, I was asked for my professional opinion as to the mental health of our President. My response was not very professional as I responded “I think he is nuts!” There is a caveat, especially important in our business, that one must carefully consider any pre-determined bias before rendering a diagnosis, and my response suggests that I had violated that rule.

In retrospect, I realize that my friend was asking for a less flippant answer to his question. Anyone who owns a TV (or uses Twitter) would probably agree that Mr. Trump’s behavior is different from what we are accustomed to seeing in our politicians. His detractors suggest this is evidence of significant mental disorder while his supporters applaud him for being earthy and “unconventional.”

I have previously written (click this link to read that post from 2016) about Mr. Trump in not very flattering terms concerning his mental status, and the non-position taken by the American Psychiatric Association of which I am a lifetime member. Those mental health professionals who insist that Trump is mentally impaired and therefore unfit to hold office in most cases make a case for the diagnosis of Narcissistic Personality Disorder. After the conversation with my friend, it occurred to me that most people might be unfamiliar with what signs and symptoms might lead to such an impression

In the first place, it may be helpful to explain what we in the shrink business mean by the term personality disorder as people sometimes overuse a term and its true meaning from a psychiatric standpoint gets watered down (for example: a person who might say upon having a bad day or disappointing day, “I’m so depressed” when in reality they aren’t clinically depressed, just a little down).

Personality Disorders | Definition by Psychiatrists

The general criteria listed in the American Psychiatric Association’s Diagnostic and statistical Manual of Mental Disorders or DSM which is now in its fifth edition. The definition of personality disorder as summarized in DSM IV is “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture” (not caused by such things as drug abuse, or other medical problems). Unfortunately, for me the criteria as listed in DSM V are more complex, and since I am a simple-minded person I will stick with DSM IV in my discussion (but perhaps more to the point I am reluctant to invest a hundred bucks in another 900 page dust collector for my bookshelf). In either case, it is clear that those who suffer from a personality disorder are very different.

Signs & Symptoms of Personality Disorders

Signs of personality disorders characteristically have been present for long periods usually from childhood. These patients are difficult to treat. Although some psychotropic medications may be helpful, the gold standard remains long-term intensive psychotherapy, a commodity which is in short supply these days. The symptoms usually serve a protective function. Consequently, patients in treatment have difficulty giving them up. An even bigger problem is that in many cases people who need treatment most are those lacking in insight. Consequently, they are convinced there is nothing wrong with them. This is especially true in cases of narcissistic and sociopathic personality disorders. They believe they are perfect in every way so why in the world would they need a psychiatrist?

Narcissism | Signs | Symptoms | Cause

The term narcissism is from the Greek myth about Narcissus who fell in love with his image while gazing into a pool of water. This did not work out too well for him for he eventually committed suicide when he realized his true love was himself. A bit of narcissism is not a bad thing…as a matter of fact most therapists would probably report that low self-esteem is one of the most common problems they see and that they spend a great deal effort trying to help their patients learn to like themselves. But as with most things in life, it is the extremes which cause us problems. We all know people who are arrogant and self-centered, but those with a narcissistic personality disorder take that to the level where their self-image is so far removed from reality that it approaches the delusional.

He/she of the narcissistic personality disorder is the master of the superlative. He is never simply good at something, he is the best. Others are not bad, they are the worst. Everything in life is measured against the perfection that only he possesses. The need to maintain this distorted image of himself dominates his life and leaves no time to consider the needs of others. He is convinced he is special, and deserves special treatment. He courts admiration or subservience in relationships, and is pathologically intolerant of criticism. This preoccupation with self, frequently distorts perceptions and may affect judgement.

As with many mental health problems, the causation is up for grabs. There may be some abnormality of brain function, environmental factors, or both. Some postulate that excessive adoration by parents is the cause, while others feel the opposite, namely that excessive criticism is the culprit. Whatever the cause, most agree that such extremes of narcissism serve the purpose of protecting a very fragile ego. His need for attention is never satisfied. Indeed, the tenacity with which the narcissist holds onto and nurtures these false opinions of himself leads one to suspect an underlying desperation at the core of his being. The most readable synopsis of narcissistic personality symptoms I have found lie in a pamphlet distributed by the Mayo Clinic as follows:

They have a sense of entitlement and require constant excessive admiration

Have an exaggerated sense of self importance

Expect to be recognized as superior even without achievements that warrant it

Exaggerate achievements and talents

Preoccupied with fantasies of success, power, brilliance, beauty or the perfect mate

Believe they are superior and can only associate with equally special people

Monopolize conversations and belittle or look down on people they perceive as inferior

Expect special favors and unquestioning compliance with their expectations

Take advantage of others to get what they want

Have an inability or unwillingness to recognize the needs and feelings of others

Be envious of others and believe others envy them

Behave in an arrogant or haughty manner, coming across as conceited, boastful and pretentious

Insist on having the best of everything (for instance the best building, golf course, yacht, wife, etc.–the examples are my words NOT Mayo Clinic’s example–they used car and office)

Narcissism & Trump

So, there you have it – all you need to make a diagnosis. You Trump watchers have certainly observed enough behaviors to decide if the shoe fits. If you conclude that the diagnosis of Personality Disorder fits, you should be concerned as to the fitness of POTUS to handle the job. Those so diagnosed are prone to react in irrational ways when their distorted view of themselves is threatened and consequently are very sensitive to any kind of criticism, often reacting with over-the-top rages. Mistakes are never acknowledged for to do so would shatter the myth of their perfection. They react poorly to stress and to change, and there is no doubt that POTUS must be under mountains of stress considering all the investigations currently underway with many of his former supporters on their way to jail.

While in the midst of writing this, I was directed by one of the friends I mentioned in my opening statement to a YouTube presentation by John Gartner, a Ph.D. psychologist at Johns Hopkins. Dr. Gartner is convinced that Trump is demented. Gartner is adamant in his diagnosis and convinced that he should be removed from office. In spite of Gartner’s intensely verbalized political views, he does make a good case for an Alzheimer’s type dementia. However, I believe the evidence he presents is not unusual for one afflicted with a narcissistic personality disorder who is under threat of losing that shield, which protects him from facing the reality of his deficiencies.

Narcissism Exposed (“s#@t hits the fan” time)

As I have mentioned in previous blogs, my major concern is that the current investigations will turn up things which he will not be able to deflect with his usual strategies of denounce, deflect, or deny. Recently, he has seemed less rational with a 2- hour long rant at the Conservative Political Action Conference, and the strange attempts to demonize John McCain months after his death. In the so-called Twitter storm from last week, he seems enraged at everyone within range. It appears that his only respite is the campaign rallies at which he is able to bask in the attention accorded him, confirming to him that he really is “The Greatest.”

Some say our President is “crazy like a fox”. It is true that he has turned self-promotion into a very successful career, even becoming the world’s most powerful man. Those same talents have served the additional function of satisfying insatiable ego needs. I believe that Trump’s narcissism governs every aspect of his life, and explains the “crazy” things he does and says. I believe that he is psychologically vulnerable and likely to demonstrate irrational and impulsive behaviors if his defenses are destroyed. With that in mind, I hope all these investigations do not burst the President’s fragile ego for that could be disastrous.

Editor’s Note: I was slow on the editing of Eshrink’s post and so much has happened since he originally wrote this article. The Attorney General released a 4-page summary of the Mueller Report on a Sunday while many of us were watching our brackets bust during the NCAA basketball tournament. I kept asking why the full report wasn’t being released to the public (the taxpayers paid for it, as POTUS continues to remind us in the context of money wasted) or at least released to Congress (it seems Nancy Pelosi wonders that, too.) However, Eshrink’s post about Narcissistic Personality made me think maybe the inner circle knows more than we think about the stability of POTUS and his psychological vulnerability that could lead to an even worse outcome. History will tell the tale… I’m sure those working inside the Oval Office will have plenty of great material for books once this crazy time in our republic’s history is behind us–if the Republic survives that is. God Bless America. We need all the help we can get!

Our mailman does not seem to like us although Barb and I both consider ourselves to be as likeable as the next guy. Whenever I meet him at our mailbox, he doesn’t respond to my characteristic jolly greeting, but simply hands me my mail, grunts, looks straight ahead and drives away. Old habits die hard and this old psychiatrist still tries to understand aberrant behaviors. Consequently, I have attempted to understand what may have precipitated his apparent animus.

The Investigation: Why does my mailman hate me?It is true that I forgot to leave his traditional tip in the mailbox at Christmas time, but of course that was several months ago.

There was also the Floyd incident, but I wouldn’t anticipate his blaming me for my dog’s exuberant behavior. Floyd loves to ride in the car and isn’t choosy about the type of vehicle or driver. Consequently, when the mail truck pulled up to mailbox one summer day, Floyd seized the opportunity. He leaped into the mail truck with excitement with big plans to accompany our mailman on his route. Unfortunately, in the process Floyd was forced to run through a gauntlet of boxes and crates of mail resulting in the rearrangement of their contents. However, the mailman was remarkably calm throughout the incident and accepted my apology, although I did note that he was muttering to himself as he restored order to the crates of mail.

My Epiphany! It’s not me. It’s those damn catalogs.After all of these deliberations, I have concluded that the ire exhibited by my mailman has the same genesis as my own.

You see, just yesterday he delivered 23 catalogs in addition to two magazines and multiple solicitations from organizations, some of whom I have never heard of, and this was only a routine day. If history is any guide, the volume will increase as the holiday season approaches. Instead of emptying my paper recycling bin once a month, I now must empty it every few days. No wonder my mailman becomes frustrated since he must stuff all that stuff in my mailbox daily.

Nothing unites like a common enemy.His pain is my pain! I sympathize with my mailman’s frustration. I get angry each time I have to unload that mailbox, cursing as I sort the scams from the legitimate mail. As a bona fide card-carrying curmudgeon I must tell you that I remember the day when if one wanted a catalog they asked for it. Today, if you order something from a catalog, you will soon be buried in an avalanche of slick pictures of beautiful people wearing cool clothes and hawking gadgets I’m sure I need but know I’ll never use. Not only do I resent their audacity of sending the catalog without me requesting it, I resent that they believe they can convince me that I look as cool in those duds as the suave handsome dude who models their stuff.
Some of these catalogs feature stuff way beyond my pay grade. For example, I do not ordinarily shop for $1500 leather jackets, $600 sweaters, or $750 shoes. One such high end catalog featured of all things a $250 pair of jeans faded in all the right places to make them look old. I do occasionally browse and sometimes find interesting inventory. For example, one which featured home health aides also had a two-page display of dildos. I was surprised to find they came in so many different sizes, shapes, and colors. Barb vigorously denies having ordered the catalog, but I have my suspicions.

The good ole’ days of face-to-face relationshipsIt is no secret that there is a flourishing market for names and addresses of potential customers and that these catalogers have no hesitation in selling us to the highest bidder. I recall the time of the mom and pop stores when the relationship between customer and seller was built on mutual trust and therefore personal. The storekeeper was more interested in customer loyalty than making a sale, trusting that if his customer was “treated right” he would come back. Likewise, the customer trusted the salesperson to give an honest representation of the product sold. In many cases shopping was as much of a social event as a series of business transactions. I suppose that now as even we former Sears catalog devotees fade-away, we will become even more depersonalized as we become numbers in Amazon’s super computer. Our computers will order from their computers, our orders will arrive untouched by human hands, and one more avenue of human interaction will close.Shopping: Art, Science, Disease, or Therapy?Enter my beautiful, charming, and aesthetically gifted wife. She is a former shopkeeper one of the last to conform to those qualities I mentioned, and whose store continues to receive rave reviews from former customers. Among her other talents she is a world class shopper. As our daughter Molly (now deceased) said regarding her Mother’s shopping prowess: “when Mom gets the scent, you better get out of her way.” For Barb, Christmas shopping is not a project, it is a mission. She scoffs at the idea that it would be much simpler for her to give the kids money and insists on finding a gift (or unfortunately–gifts…plural) which are perfect for each one whether they realize it or not. Things to be considered include: hair and eye color, stature, personality, and consideration of their known personal preferences unless those preferences are in extremely poor taste.
Within the past year the last department store as well as the last men’s store in our town closed their doors. I recall a time when our main street hosted three department stores and multiple specialty shops which have all folded as the big boxes took over. Having fought and lost the good fight with the big guys, and since she places online shopping in the same category as those big box adversaries, the best Barb can do is to reluctantly shop via catalogs even though she disapproved of the one featuring dildos. I presume this change in her shopping habits is responsible in large part for the appearance of our names on a few hundred mailing lists.

The List Contagion: It’s a real thingIt’s not only the merchandisers who will pursue you. Barb is a sucker for those tear-jerking ads on TV, which has resulted in reams of solicitations for real and non-existent charities. I wonder if they make more money selling my name and address than from my feeble contributions. In my zeal to become a good steward of my government, I once made the mistake of contributing to a political campaign online. Now, I start my day by deleting pleas to contribute to this or that political cause or candidate. They assure me that without my contribution a worldwide calamity is immanent or that I will be to blame for the extinction of the white rhino.

Privacy?
On a more serious note, it has been said that with a few key strokes one can know more about me than I do about myself. This is undoubtedly true e.g. I don’t know where I ate a year ago but that info is available somewhere. Our privacy is said to have been eroded, but it is probably more accurate to say it is gone. Now, as more DNA results are collected not only will more be known about your behavior but your body and your relatives. Nevertheless, the blatant disregard of our rights to privacy as this little essay illustrates is only one small example yet enough to piss me off big time.

Ground Zero
Maybe my overzealous anger about the catalogs goes beyond the senseless time spent sorting and recycling and even beyond the invasion of my privacy. Maybe it’s a symptom of something bigger that concerns me. A change in our society that is worrisome. While many say technological changes make it easier than ever to connect with one another, it seems we are more disconnected than ever. Less human interaction. More loneliness. Clicking the chat button as you order gifts on the internet, or even talking to a live person when you order from one of the thousand or so catalogs, is a poor substitute for the process of old-fashioned shopping at the aforementioned brick and mortar establishments where you talked to retail clerks, shop owners, and even fellow shoppers.

A little over 100 years ago, a sociologist name of Emile Durkheim coined the term Anomie which he used to describe situations where societies in large measure feel a sense of alienation because their only feeling of attachment is to the system in which they don’t believe or feel a part of. He thought this came about due to division of labor (this was in the midst of the industrial revolution) and rapid change from a traditional society to a modern society.

The pace of changes which Durkheim witnessed were trivial compared to the last 50 years, and it change continues to accelerate at a speed almost beyond our ability to comprehend. Yesterday, I awoke to hear news of the second mass shooting in less than two weeks. I believe it noteworthy that most of the perpetrators of these horrible acts were described as people with few if any acquaintances and no one who was willing to call them a friend. They were described as quiet and uninvolved in their communities, in short: alienated.

It also seems noteworthy that in spite of relatively good economic times, suicide rates in the U.S. have increased 24% from 1999 to 2014. Likewise, murders increased 8.6% in only one year (2016). According to the non-profit that tracks gun violence in the USA, (www.gunviolence.org) incidents have increased each year since they started tracking statistics in 2014. Conventional wisdom is that our current President was elected and continues to have widespread support from those who feel they have been “disenfranchised.”

Who is the patient?
This all suggests to me that we need to look farther than individuals with mental illness as the major factor in gun violence. It may be that it is our society that is ill, and in need of treatment. Human connection, kindness, and compassion might not help cure all of society’s mental illnesses, but it can’t hurt.

P.S. Catalog UPDATE
By the way, I just now picked up today’s mail and there were only 18 catalogs, but an armload of solicitations for money, some bills, and a letter from my only friend who still writes via snail mail. Remember to be kind to your mailperson (especially this time of year). There may be other Floyds out there and I’m sure there are even more catalog targets like me and Barb on every mail carrier’s route. (Break for reminiscing): When I was in college a couple of centuries ago I worked as a mailman during Christmas breaks, and occasionally someone would invite me in for a cup of hot chocolate on the coldest days. I wonder if that happens anymore.

Editors Note: While editing eshrink’s blog, I found this non-profit whose mission is to help us cancel unwanted catalogs: Catalog Choice . However, I haven’t told eshrink yet because I don’t want to rain on his curmudgeon complaint parade…he’s on a roll and I think it energizes him! Love you dad.

This title was chosen by my son for reasons which will soon be obvious. His youngest has just left home, this time for good, and he and Sue are now presiding over the proverbial empty nest. It is a frequently quoted truism that if you truly love someone you will let them go when it is in their best interest to leave. I was reminded of this last night as I watched Casablanca…one of my favorite movies in which that theme was paramount. Though it is a noble act to let go of those you love, separation is painful, and usually results in significant changes in our lives.
We experience multiple types of transitions during our lifetimes, but since we are at heart social beings, or to put it more crudely, tribal in nature, changes in our relationships are apt to generate the most intense feelings. It is something of a paradox that as the world gets smaller, we find so many people of whom we care to be geographically farther away. Yes, indeed we are able to communicate with ease yet Facebook is a rather poor substitute for a next-door neighbor, or a relative living in the neighborhood. Prior to the industrial revolution, one’s cadre of friends and relatives was unlikely to change very much, and most people were born and died in the same place, often even in the same house. Now neighborhoods are in a constant state of flux, and there is a lower expectation of lifelong relationships.

STUCK WITH THEM
No wonder our children are among the very most important people of our lives. Since humans require nearly 2 decades to reach maturity and carry our DNA, we tend to form very strong bonds. We are often identified as “Johnny’s” father or mother. We live vicariously through them and share their triumphs, failures, joys, and sorrows. In many ways they are our second chance at life as we attempt to steer them away from repeating our mistakes. As the years go by our intimate involvement in their lives blurs with our own–they become part of us and in doing so shape our identity, i.e. who we are.GRIEF WITHOUT A CORPSE
With all that in mind, it is not surprising that separation anxiety is a common affliction. When the kids grow up and leave, something more than their presence is missing. It is as if a part of ourselves is gone. Not only is the nest empty, but we feel an emptiness within ourselves, a kind of psychological amputation. In my experience, this emptiness is most profound when the youngest one leaves for with it comes the realization that nothing will ever be the same. This time they are leaving to build their own nest.THE FUN TIMES
Life is an ever-changing process. We begin as totally helpless and dependent creatures and experience a myriad of transitions during our lifetime all designed to produce an individual capable of building and presiding over that nest. Some of those changes are more dramatic than others. There are the first steps, the first words, the first solo bicycle ride, the first day of school, the first sleep over and a few thousand other adventures all with a goal of achieving sufficient independence to allow them to face the world on their own.WHY DID I GET INTO THIS?
But it is not all sweetness and light. There is the messiness, the lack of discipline, the terrible twos, the out of bounds phase, the adolescent rebellion, the sleepless nights, and the continued testing of limits to name a few of the frustrations inherent in the child-rearing business. Those little buggers are also expensive. According to the USDA the average cost of rearing a child in 2016 was over $245,000 which does not include costs for higher education (but for the kids, I could have been a millionaire). Considering all the chaos they generate it is little wonder that we don’t occasionally wish them to be grown up however; one should keep in mind the maxim to “be careful what you wish for.”BEGINNING AND END
According to the Bureau of Labor Statistics 67.3 % of high school graduates enrolled in college last year (2017). It seems safe to assume that most of these kids would leave home while in school, but retain a close connection to their old familiar environs. In many cases the college transition is a prelude and training for that final fly away. The days when we dumped kids and their gear off to a strange new environment were certainly memorable to Barb and me.
Our first experience with the off to college scenario was painful for all involved. Molly, our firstborn (now deceased), who suffered from serious medical and emotional problems was unable to complete that transition. Next in the line of succession was Peter, who was much too macho to display his feelings, but I was already missing him by the time we pulled away from his dorm. After a four-year hiatus, it was Trudy’s turn. Trudy, the adventurous one, was on the phone almost immediately, tearful and very upset to find beer being consumed at the sorority rush parties that she attended. We had no idea where this came from for temperance had never been emphasized at home. As you probably already suspect. her distress was short lived and as was her habit she soon became involved in everything.THE LAST ONE STANDING
Of course, those separations were painful, but none so telling as Maggie’s departure for we were now returning to a house inhabited only by Barb, myself and Grover the dog. Maggie was one who had insisted on an out of state school, for she was eager to assert her independent status. She wanted distance from childhood connections. Her reaction to the college transition was a convincing testimonial for that “be careful what you wish for” thing. Permanently engraved in my memory is the sight of that sobbing, skinny little red-haired girl who stood there all alone in that huge empty parking lot making feeble attempts to wave goodbye as we pulled away. Barb wanted to go for one last hug, but I insisted she had already had several last hugs. We were later told that she cried for the next month and lost 20 pounds. [See an earlier blog post about Separation Anxiety + Mental Health}NOT ALL SWEETNESS AND LIGHT
In case you are thinking this gang of mine is the Partridge family incarnate, think again. It is true that to date we have come through our transitions relatively unscathed, but not without trials and tribulations. In spite of their best efforts some families are overwhelmed by circumstances beyond their control. Barb and I are indeed fortunate that in spite of our screw-ups we have ended up with 2 generations of exceptional people, and the beat goes on.STILL AT IT
It so happens that this month marks the beginning of significant transitions for every one of my Grandchildren which of course they will undoubtedly handle better than do their parents (or Grandparents for that matter). My three oldest grandchildren are already emancipated and starting new and more challenging jobs. Another is off to her first year in college, and our youngest is entering high school. As mentioned in my opening statement, Carter’s room is empty, and home is now in another city far away. Trudy’s is the only nest still occupied.LIFE GOES ON
Whatever distress the kids may feel from leaving those years of memories behind is apt to be short lived compared to that of their parents. There is hope for Mom and Dad however. In return for enduring the vicissitudes of child rearing God has rewarded us with grandchildren. Thus, we have an opportunity to get all the goodies and none of the crappy stuff ,which leaves me wondering what it would be like to be a great grandparent. Stay tuned for the answer!

Last night I happened upon a documentary about death on PBS. It included an introductory presentation by a woman who reports that she had found resolution to her fear of death by directly confronting it. She had made a point of viewing dead bodies at every opportunity and had even taken a job at a crematorium, which seemed like overkill to me. To complete her story, a vignette of that entire process was shown. I did not find watching the incineration of bodies as particularly entertaining, and Barb left the room saying she was repulsed. In spite of my interest, (I had always wondered how this procedure was done), I shared Barb’s feelings perhaps even more intensely for this is the method I had chosen for my disposal.

THE BIG QUESTION
Many years ago, I think it was the late 60s, Peggy Lee recorded a song titled: IS THAT ALL THERE IS? which has haunted me all these years for it expresses to me the most fundamental existential questions. What is life, where did it come from, why are we here, how did it happen, who or what caused it? When the answers to these questions seem almost within our reach, new questions arise and we end up confounded all over again. We humans are undoubtedly unique in our ability to even ponder such questions. As a matter of fact, we have no clear idea what life is let alone what it is all about. Our definitions of life are simplistic and do little to help us understand what it is. For example, for some time there have been efforts underway to actually synthesize a living cell, but those involved in such efforts cannot agree on the criteria for determining when something is alive.

WHAT IS DEATH?
Death on the other hand is defined as the absence of life, but is it? At this time of the year, one third of the world’s population is celebrating their belief that life is eternal. Muslims likewise hold strong beliefs in an afterlife as do many other religions. Freud described religion as a symptom of neurosis or in some cases psychosis. Karl Marx famously insisted that religion was the opiate of the masses. Both saw religious dogma as a defense against the vicissitudes of life: for Freud, defense from anxiety, and for Marx defense from the pain of domination. In spite of his atheistic beliefs Freud was reported to have said during a prolonged, and painful terminal illness that he envied those who had strong religious beliefs.
As our brains evolved to become huge cauliflower like globs of neurons, we developed the ability to not only perceive reality but to predict future events. This ability has served us well, but there is a down side in that we became aware of our mortality. Floyd, my dog who sleeps at my feet as I write this, is able to predict certain outcomes. For example, he has learned some of the routines of the house and knows when I put on a coat that he might be able to bum a ride. He will undoubtedly see dead animals during his lifetime, may even experience grief, but I feel fairly certain that he does not realize that in a few short years he will die.

RELIGION AND THE DEATH PROBLEM
Back in my younger days when as an academic I knew almost everything about everything, I found that death was one of those things even I did not understand. I was especially interested in how our awareness of mortality affected our thinking, values, behaviors, personality development, and even our mental health. My research on the subject of attitudes toward death indicated that certain diagnostic categories of psychiatric patients had attitudes significantly different from the norm. All very interesting, but I was left with the classic chicken egg dilemma, did their illness cause their unique attitudes or did those attitudes contribute to the illness? But that’s how it is with any scientific endeavor, to answer one question will only lead to more questions.
The study did tend to confirm what everyone already knew in that some people look forward to death while others fear it. In the former category is the late Billy Graham who on multiple occasions insisted that he was looking forward to his earthly death, and the beginning of a new (much better) life. Muslims are so convinced of an afterlife in paradise that they are willing to martyr themselves to ensure their admission. As a matter of fact, all religions seem to have in common the pursuit of a solution to the death problem. Those of strong faith have been shown to have less fear of dying, but in one study those adherents uncertain of an after-life were even more fearful than atheists who were convinced that there was nothing after death.

DEATH OR RELIEF?
Death may also be attractive to those suffering from extreme pain either physical or mental. Patients whom I have known to have suffered both serious physical and emotional distress at various times in their lives invariably report the emotional pain to be more difficult to endure. When combined with feeling there is no hope, for such people suicide may seem their only option.

On one occasion in the days before Google, I was approached by a patient asking what would be the lethal dose of phenobarbital. He reported that his mother had been ill for several years with several surgeries leaving her without ability to speak, a horribly disfigured face, and severe pain. She was on large doses of pain medications, and her illness was terminal. She had told her family that after careful consideration she had decided she wished to die sooner rather than later and wanted her family to be with her as she died. Had she been a family pet her assisted suicide would have been declared merciful, but in her case it was criminal. Go figure. On the other hand many agree that to countenance euthanasia is to start down a slippery slope.

CLINGING TO LIFE. FIGHTING DEATH.
There are others for whom life is so precious, or is it that death is so threatening, that they cling to life in spite of enormous pain or disability. Such was the case with my daughter who shortly before her death said: “I don’t want to die Daddy.” Was she afraid? I will never know for my response was to reassure her she was not dying rather than to address her feelings about the death she knew was imminent. Thus, her cry for support was brushed off and she was left to deal with the most difficult time of her life alone. I should have known better. Sometimes it is difficult to practice what you preach.

A recent example of one who chose to follow Dylan Thomas’s advice to “Rage, rage the dying of the light…….” Is exemplified by the late Stephen Hawking, who was diagnosed with Amyotrophic lateral sclerosis as a graduate student and told he could not be expected to live more than two years. In spite of total paralysis and the loss of his ability to speak, he went on to become a major contributor to the science of cosmology and was described by some as a modern day Isaac Newton. He was a prolific writer in both the scientific and lay literature in spite of limited ability to communicate. In his later years, he gave lectures all over the world with the use of a voice synthesizer operated by his only remaining functioning muscle group which was in his cheek.

LETTING GO
Sometimes death can be viewed as an opportunity to be reunited with a loved one. One very personal example of this was with the death of my Mother. My Father had been dead for a couple of years and Mother was staying with us. Her only known medical problem was a few episodes of cardiac arrhythmia one of which had resulted in hospitalization and successful treatment. I suspected she would be discharged the following day and stopped in to see her as I made morning rounds. I was surprised at her response when I asked her how she was feeling when she said: “I am feeling just fine, but I have been thinking a lot lately and have decided it is about time for me to be out there (the cemetery) beside your Father.” I thought little of her comment and went on to my office. A short time later I received a call from her nurse telling me she had died. We should all be so lucky as to go that way, in charge and at peace. This and similar stories have led me to believe that we have more control over our demise than is apparent.

SEX AND DEATH?
Perhaps the weirdest thanatophilic attitude toward death is in its libidinization which was not only observed in my research but in Greek mythology. In the story of “The Rape of Persephone,” Pluto, guardian of the underworld ascended from Hades to seduce the maiden Persephone. Throughout history this theme has been repeated many times in different iterations. You may be thinking: how can there be anything sexy about death? I told you it was weird. This brings me back to the young lady who was interviewed extensively on the PBS special. She not only presented her story of how she overcame her fear of death, but was filmed giving a lecture to a group of alleged thanatophobes. It occurred to me that she possibly could have gone overboard as she talked of the joys of death in a husky voice accompanied by a sexy smile. But in case you want to learn about even weirder stuff you might want to check on the necrophiles who enjoy sex with corpses. There is also John Wayne Gacy who admitted to having orgasms as he watched his victims die.

NEAR DEATH EXPERIENCES
None of those interviewed in the PBS documentary seemed more certain of life after death than those with histories of near death experiences. Their stories were consistent and the interviewees were very credible. Many others speak of witnessing from above the attempts made to resuscitate them, and report seeing a tunnel with a bright light in the distance. There have also been some who have reported very unpleasant experiences, and following their recoveries vowed to change their ways. There is one neurologist who suggested these experiences were simply the result of cerebral ischemia (diminished blood supply to the brain), but there is little doubt in the minds of these survivors that their experiences were real. One such survivor suffering from a terminal cancer reported she was looking forward to her death and we were told she died two months following the filming of the program. The others all said their lives had been changed since the experience, and that they had developed a kind of serenity they had never known previously. Although not mentioned in the broadcast, I am also aware of at least two books written about going to heaven and one describing a 20 minute visit to Hell, accounts which I found less credible.

CREATING YOUR OWN AFTERLIFE
Spookiest of all in my opinion was an in depth look at the so-called cryogenic procedure in which bodies are frozen in liquid nitrogen with the hope that in future years technology will allow their illnesses to be cured, and they will be able to do a secular version of the Lazarus trick. Cellular biologists believe it is impossible to do even a very quick freeze without doing permanent damage to the body’s cells. Nevertheless, there are people who are willing to pony up large sums of money to have their bodies frozen and stored in hopes of being brought back to life. One website reports they have over 100 such bodies stored in huge tanks of liquid nitrogen. As for me, I think I would prefer to take a shot at heading down that tunnel toward the bright light.

DEALING WITH OUR MORTALITY
There are many behaviors unique to humans for which one could make a good case to result from awareness of our mortality and even the concept of death. Denial is the most powerful tool that can be used to decrease anxiety, and typically the way most of us deal with the reality of death. Those things we don’t understand are the ones we find most frightening. Freud for all his foibles had much to say about death, although discounting religion, he presented some interesting comments about our denial. One which rang true to me was his statement: “It is indeed impossible to imagine our own death, because whenever we attempt to do so we can perceive that we are in fact still present as spectators.” I can’t help but wonder if he got this idea from Mark Twain’s story about Tom and Huck attending their own funeral. Nevertheless, he does make a point. We like to give instructions as to how our funeral or lack of should be conducted sometimes with great detail, and without consideration for the idea that such services should be for the benefit of those who grieve. Do we really believe we will be able to hear what hymns are played?
In spite of our knowledge of the inevitability of death we continue to seek token immortality. We select monuments, have portraits made, buy life insurance, establish charitable trusts, write wills, work hard in order to be able to leave something behind, and even write blogs in hopes we will be remembered; and continue to live in the minds of others. Not surprisingly there are often attempts to retain control after death. I recall one example of a friend who was noted to be an in control kind of guy who liked to keep his wife under his thumb. He wrote a will in which he specified that her inheritance would go to charity in the event she should remarry after his death. There are so many other questions which have gone unanswered. For example, to name a few: why do some enjoy the thrill of risking their life, why do some like to frighten others with the threat of death, why do some appear to actually enjoy killing. We seem to be unique among the animal kingdom in those behaviors.

ARE THERE ADVANTAGES TO THE REALIZATION OF OUR OWN MORTALITY?
Lest you think I am totally morbid in these thoughts, I should admit there are some obviously useful things surrounding this mortality thing. We tend in many ways to view death as punishment. We use terms like “he deserved to die,” and “the wages of sin are death.” Throughout history, assassinations have been carried out to punish those accused of misdeeds, and the most serious crimes are still punished by death. If we were convinced we would live forever, would we behave instinctively without regard to consequences, in other words would we have developed a super-ego? In like fashion what about creativity and the urge to complete projects if time were not limited? There would be no need for monuments or for offspring to mourn. Would we feel the need to band together with others? It sounds to me as if life would be boring.

MY STRATEGY
Well, enough of this death stuff. I hope the next PBS program will be about life. Meanwhile, I plan to adopt the “eat drink and be merry” strategy. Barb recently told me she had decided to concentrate on living each day to the fullest as long as she could. I suppose this would not leave much time for worrying about such mundane issues as dying. Maybe she will be willing to give me some lessons.

Addendum by retired eshrink editor:
My dad and I discussed the topic of this blog before he wrote it. I told him of a pivotal moment during college when a marketing professor posed the question, “What if this is all there is? Despite what you’ve been taught in church or by your parents, what if this life is all you get?”

It was if a light bulb went off! Religion uses “heaven” and “hell” (the “afterlife” in general) to relieve us of the anxiety of our own mortality and in some instances, to control us. You want to get to heaven. You don’t want to go to hell. Here’s what you need to do. As if, all chaos would ensue if we thought this was the one life we get to have.

Indeed, that was the point I got from this professor. The realization that this life is the one that is real and I better be a full participant because it’s the only one I know I have. Don’t use an “afterlife” idea to put off living this life fully. Don’t get me wrong, I hope there’s something really good after this life. My version of “heaven” is being able to use the heaven TV network to check in on all my people to see what’s going on because I don’t want to miss anything! Also, I would like to create my own weather, get to choose my own “age” during my time in heaven, visit with everyone else who is dead, and most of all, get all of those big questions answered. I freely admit that I’m afraid to die because I’m afraid of the unknown…I’m with Freud, I’m envious of those people who have no doubt in religion’s teaching of an afterlife. However, I must admit I have never understood why highly religious people who think their dead family member has gone home to Jesus to the next life, cry so much at the funeral. If you truly believe that without a doubt, wouldn’t you be happy for them?

However, I do believe there is something more and hope there is something more, but no proof to date.

So, I try to use mortality to make sure I live well in this moment that I have been so fortunate to be given and even more, to put life’s perceived “stresses” in perspective. “It’s not life and death” I’ll tell myself.

Since my husband died suddenly at a fairly young age , I also use “death” as a way to live my life double for those who don’t get to be here. I try very hard not to take one minute for granted. Life’s short. It’s not a dress rehearsal. Treasure the gift. Be present. Make every minute count.